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An Index of Left Ventricular Contractility Loss due to Mechanical Dyssynchrony for the Prediction of Response to Cardiac Resynchronization Therapy
The 20th Annual Scientific Meeting
SY6-4 Pulmonary Hypertension in Severe Heart Failure Patients With Implantable Ventricular Assist Device Tatsuo Aoki1, Koichiro Sugimura1, Shunsuke Tatebe1, Saori Yamamoto1, Nobuhiro Yaoita1, Kimio Satoh1, Masatoshi Akiyama2, Shunsuke Kawamoto2, Yoshikatsu Saiki2, Hiroaki Shimokawa1; 1Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan Backgrounds: In severe heart failure (HF) patients after ventricular assist device (VAD) implantation, incidence of pulmonary hypertension (PH) with elevated pulmonary vascular resistance (PVR) remains to be elucidated. Methods and Results: In 26 severe HF patients (mean age 44 years old, male 21 (81%)) who underwent elective VAD implantation from May 2011 to May 2016 in our hospital, incidence and characteristics of pulmonary hypertension were examined. Before VAD implantation, all patients showed post-capillary PH (mean pulmonary arterial pressure (mPAP) >25 and pulmonary arterial wedge pressure (PAWP) >15 mmHg), and 8 of them (31%) had PH with elevated PVR (>2.5 Wood unit (WU)). After VAD implantation, mPAP (38 ± 9 to 20 ± 8 mmHg) and PAWP (29 ± 7 to 10 ± 5 mmHg) were significantly decreased (N = 19, both of P < .01). PVR was significantly decreased in the patients with elevated PVR after VAD implantation (4.6 ± 1.8 to 3.0 ± 1.8 WU, P = .04), but not in those with normal PVR. Furthermore, after VAD implantation, two of them still showed elevated PVR, and de-novo elevation of PVR (>2.5 WU) was observed in 3 cases. Conclusions: Although VAD implantation might improve mild pulmonary vascular disorder in severe HF patients, a part of the patients showed persistent or de-novo elevation of PVR, suggesting that hemodynamics evaluation after VAD implantation could be important to reveal potential pulmonary vascular disorder.
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failure experts suggest practical guidance, which emphasize “the earlier, the better” (Int Care Med 42:147, 2016). For improving and avoing further organ injuries in AHF, organ-interactions should be considered,ie., heart and lung, kideny, liver, or vessels. I would like to summarize important findings regarding organ injuries from learned lessons from registries.
SY8-2 Hyperuricemia in Heart Failure Hiroyuki Tsutsui; Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
SY7-2
High serum uric acid (UA) or hyperuricemia has been well demonstrated to be associated with poor outcomes in patients with heart failure (HF). Hyperuricemia in HF may be due to the upregulation of the xanthine oxidase (XO), a key enzyme in the generation of oxygen free radicals. It may induce proinflammatory activation, impaired oxidative metabolism, and vascular endothelial dysfunction in HF. However, previous clinical trials reported that XO inhibition with oxypurinol or allopurinol failed to improve clinical outcomes in HF patients with reduced ejection fraction (EF) and elevated UA levels. Febuxostat is a novel UA-lowering agent by inhibiting XO through a different mechanism from allopurinol. It has been shown to lower serum UA and inhibit the production of XO-derived reactive oxygen species compared to allopurinol. It may be efficacious and safe even in patients with mild to moderate renal impairment due to its elimination via both hepatic and renal pathways. The LEAF-CHF study (Effect of urate LowEring Agent Febuxostat in Chronic Heart Failure patients with hyperuricemia; UMIN000013330) is ongoing to evaluate the effect of febuxostat on plasma BNP levels in patients with HF with reduced EF and hyperuricemia compared to conventional therapy. Based on the increasing recognition of the need to treat hyperuricemia in HF, clinical evidence needs to be established.
An Index of Left Ventricular Contractility Loss due to Mechanical Dyssynchrony for the Prediction of Response to Cardiac Resynchronization Therapy Hiroyuki Iwano; Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Japan
SY8-4
Cardiac resynchronization therapy (CRT) improves left ventricular (LV) systolic function, symptoms, and outcomes in patients with advanced heart failure by correcting the dyssynchronous LV contraction. These responses to CRT are varied among the patients and echocardiographic parameters of dyssynchrony have been tested to predict the response which, however, is still challenging. One of the reasons for this inappropriate predictive value of the mechanical dyssynchrony could be that the response to CRT depends not only on the degree of mechanical dyssynchrony but on that of residual contractility. From the standpoint of this consideration, several parameters which took account for the LV contractility together with dyssyncyrony have been produced and they were reported to associate with CRT response better than dyssynchrony parameters. We also reported a parameter which expresses the amount of LV contractility loss due to dyssynchrony, strain rate dispersion index (SRDI). SRDI is calculated as: (average of segmental peak systolic strain rates)— (peak global systolic strain rate). The former segment expresses the estimated global LV systolic function after resynchronization and the latter one does the actual global systolic function in the presence of dyssynchrony. Therefore, SRDI can be regarded as the estimated increase of LV global systolic function by the resynchronization. In this presentation, we will present about the concept and predictive value for the CRT response of SRDI.
SY7-5 Should Cardiac Resynchronization Therapy be Indicated Among Stage D Heart Failure Patients? Koichiro Kinugawa; The Second Department of Internal Medicine, University of Toyama, Japan
Pathophysiology of Cerebro-Cardio-Renal Continuum in Patients With Left Ventricular Hypertrophy Naoki Nakagawa, Naoyuki Hasebe; Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan Chronic kidney disease (CKD) is now recognized as a risk factor for both end-stage renal disease and independently for cardiovascular disease (CVD), because of the prevalence of many traditional CVD risk factors, such as hypertension, diabetes, dyslipidemia, and left ventricular hypertrophy (LVH). Our study demonstrated that the poor blood pressure control have an affect on worsening atrial fibrillation (AF) possibly via left ventricular diastolic dysfunction, followed by left atrial overload. In addition, in 470 patients with acute stroke in our hospital, we found a higher prevalence of AF (31.4% vs. 15.1%, P < .05) and cardiogenic embolism (34.3% vs. 24.5%, P < .05) in patients with CKD (n = 140) than without CKD (n = 330), suggesting that increased left atrial volume is predisposed to AF, followed by stroke caused by cardiogenic embolism. Recently, we investigated the associations between malnutrition, estimated glomerular filtration rate (eGFR), LVH and cardiovascular events in consecutive 161 patients (82 males, mean age of 63.5 ± 9.2 years) who were followed for >7 years. The eGFR was correlated with left atrial dimension and left ventricular mass index. In addition, malnutrition, low eGFR and LVH were independent determinants of cardiovascular event incidence; they synergistically increased rates of these events in the long term. Our discussion will focus on pathophysiology and management of cerebro-cardio-renal continuum in patients with LVH from our own experiments.
SY8-5 This title contains in itself contradiction, since the definition of stage D is based on the unresponsiveness to the guideline-directed medical therapy that should be applied to stage A to C. Therefore, patients with stage D heart failure had been evaluated for the indication of CRT beforehand, and they are not indicated or unresponsive. However, the real world clinic is not necessarily the gildeline world, and I will discuss in this session whether advanced heart failure could be reversed by somewhat belated CRT or not.
SY8-1 Organ Injuries in Acute Heart Failure—Lessons From Registries Naoki Sato; Cardiology and Intensive Care Unit, Nippon Medical School MusashiKosugi Hospital, Japan Lots of registries for acute heart failure (AHF) has been conducted in Asian as well as in western coutries. We could learn lots of stratgies from these registries,which is clarfing theta delayed managements were related to poor outcome. Recently the heart
Heart Failure and Sleep-Disordered Breathing: Impact of Positive Airway Pressure on Patients With Heart Failure Akiomi Yoshihisa, Tetsuro Yokokawa, Satoshi Suzuki, Yasuchika Takeishi; Department of Cardiovascular Medicine, Fukushima Medical University, Japan Heart failure (HF) is mutually associated with sleep-disordered breathing (SDB) including obstructive sleep apnea (OSA) and central sleep apnea (CSA). It has been reported that positive airway pressure (PAP) such as continuous positive airway pressure (CPAP) and adaptive servo ventilation (ASV) improve not only SDB but also pulmonary congestion, cardiac function and partly prognosis. PAP therapy is usually applied for treatment of decompensated HF, and OSA treatment using CPAP is generally accepted in patients with HF and OSA. On the other hand, CSA treatment using CPAP or ASV in patients with HF and CSA is controversial. Recently, SERVE-HF study presented that ASV therapy for HF with left ventricular ejection fraction less than 45% and CSA possibility increased cardiac death. It appears that there are several considerable problems with regard to degree of congestion and cardiac function of HF patients and setting of pressure of ASV. We would like to present the linkage of HF and SDB, impact of PAP on HF patients, and matters that require attention of PAP treatment in HF patients.
SY6-4 Pulmonary Hypertension in Severe Heart Failure Patients With Implantable Ventricular Assist Device Tatsuo Aoki1, Koichiro Sugimura1, Shunsuke Tatebe1, Saori Yamamoto1, Nobuhiro Yaoita1, Kimio Satoh1, Masatoshi Akiyama2, Shunsuke Kawamoto2, Yoshikatsu Saiki2, Hiroaki Shimokawa1; 1Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan Backgrounds: In severe heart failure (HF) patients after ventricular assist device (VAD) implantation, incidence of pulmonary hypertension (PH) with elevated pulmonary vascular resistance (PVR) remains to be elucidated. Methods and Results: In 26 severe HF patients (mean age 44 years old, male 21 (81%)) who underwent elective VAD implantation from May 2011 to May 2016 in our hospital, incidence and characteristics of pulmonary hypertension were examined. Before VAD implantation, all patients showed post-capillary PH (mean pulmonary arterial pressure (mPAP) >25 and pulmonary arterial wedge pressure (PAWP) >15 mmHg), and 8 of them (31%) had PH with elevated PVR (>2.5 Wood unit (WU)). After VAD implantation, mPAP (38 ± 9 to 20 ± 8 mmHg) and PAWP (29 ± 7 to 10 ± 5 mmHg) were significantly decreased (N = 19, both of P < .01). PVR was significantly decreased in the patients with elevated PVR after VAD implantation (4.6 ± 1.8 to 3.0 ± 1.8 WU, P = .04), but not in those with normal PVR. Furthermore, after VAD implantation, two of them still showed elevated PVR, and de-novo elevation of PVR (>2.5 WU) was observed in 3 cases. Conclusions: Although VAD implantation might improve mild pulmonary vascular disorder in severe HF patients, a part of the patients showed persistent or de-novo elevation of PVR, suggesting that hemodynamics evaluation after VAD implantation could be important to reveal potential pulmonary vascular disorder.
•
JHFS
S157
failure experts suggest practical guidance, which emphasize “the earlier, the better” (Int Care Med 42:147, 2016). For improving and avoing further organ injuries in AHF, organ-interactions should be considered,ie., heart and lung, kideny, liver, or vessels. I would like to summarize important findings regarding organ injuries from learned lessons from registries.
SY8-2 Hyperuricemia in Heart Failure Hiroyuki Tsutsui; Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
SY7-2
High serum uric acid (UA) or hyperuricemia has been well demonstrated to be associated with poor outcomes in patients with heart failure (HF). Hyperuricemia in HF may be due to the upregulation of the xanthine oxidase (XO), a key enzyme in the generation of oxygen free radicals. It may induce proinflammatory activation, impaired oxidative metabolism, and vascular endothelial dysfunction in HF. However, previous clinical trials reported that XO inhibition with oxypurinol or allopurinol failed to improve clinical outcomes in HF patients with reduced ejection fraction (EF) and elevated UA levels. Febuxostat is a novel UA-lowering agent by inhibiting XO through a different mechanism from allopurinol. It has been shown to lower serum UA and inhibit the production of XO-derived reactive oxygen species compared to allopurinol. It may be efficacious and safe even in patients with mild to moderate renal impairment due to its elimination via both hepatic and renal pathways. The LEAF-CHF study (Effect of urate LowEring Agent Febuxostat in Chronic Heart Failure patients with hyperuricemia; UMIN000013330) is ongoing to evaluate the effect of febuxostat on plasma BNP levels in patients with HF with reduced EF and hyperuricemia compared to conventional therapy. Based on the increasing recognition of the need to treat hyperuricemia in HF, clinical evidence needs to be established.
An Index of Left Ventricular Contractility Loss due to Mechanical Dyssynchrony for the Prediction of Response to Cardiac Resynchronization Therapy Hiroyuki Iwano; Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Japan
SY8-4
Cardiac resynchronization therapy (CRT) improves left ventricular (LV) systolic function, symptoms, and outcomes in patients with advanced heart failure by correcting the dyssynchronous LV contraction. These responses to CRT are varied among the patients and echocardiographic parameters of dyssynchrony have been tested to predict the response which, however, is still challenging. One of the reasons for this inappropriate predictive value of the mechanical dyssynchrony could be that the response to CRT depends not only on the degree of mechanical dyssynchrony but on that of residual contractility. From the standpoint of this consideration, several parameters which took account for the LV contractility together with dyssyncyrony have been produced and they were reported to associate with CRT response better than dyssynchrony parameters. We also reported a parameter which expresses the amount of LV contractility loss due to dyssynchrony, strain rate dispersion index (SRDI). SRDI is calculated as: (average of segmental peak systolic strain rates)— (peak global systolic strain rate). The former segment expresses the estimated global LV systolic function after resynchronization and the latter one does the actual global systolic function in the presence of dyssynchrony. Therefore, SRDI can be regarded as the estimated increase of LV global systolic function by the resynchronization. In this presentation, we will present about the concept and predictive value for the CRT response of SRDI.
SY7-5 Should Cardiac Resynchronization Therapy be Indicated Among Stage D Heart Failure Patients? Koichiro Kinugawa; The Second Department of Internal Medicine, University of Toyama, Japan
Pathophysiology of Cerebro-Cardio-Renal Continuum in Patients With Left Ventricular Hypertrophy Naoki Nakagawa, Naoyuki Hasebe; Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan Chronic kidney disease (CKD) is now recognized as a risk factor for both end-stage renal disease and independently for cardiovascular disease (CVD), because of the prevalence of many traditional CVD risk factors, such as hypertension, diabetes, dyslipidemia, and left ventricular hypertrophy (LVH). Our study demonstrated that the poor blood pressure control have an affect on worsening atrial fibrillation (AF) possibly via left ventricular diastolic dysfunction, followed by left atrial overload. In addition, in 470 patients with acute stroke in our hospital, we found a higher prevalence of AF (31.4% vs. 15.1%, P < .05) and cardiogenic embolism (34.3% vs. 24.5%, P < .05) in patients with CKD (n = 140) than without CKD (n = 330), suggesting that increased left atrial volume is predisposed to AF, followed by stroke caused by cardiogenic embolism. Recently, we investigated the associations between malnutrition, estimated glomerular filtration rate (eGFR), LVH and cardiovascular events in consecutive 161 patients (82 males, mean age of 63.5 ± 9.2 years) who were followed for >7 years. The eGFR was correlated with left atrial dimension and left ventricular mass index. In addition, malnutrition, low eGFR and LVH were independent determinants of cardiovascular event incidence; they synergistically increased rates of these events in the long term. Our discussion will focus on pathophysiology and management of cerebro-cardio-renal continuum in patients with LVH from our own experiments.
SY8-5 This title contains in itself contradiction, since the definition of stage D is based on the unresponsiveness to the guideline-directed medical therapy that should be applied to stage A to C. Therefore, patients with stage D heart failure had been evaluated for the indication of CRT beforehand, and they are not indicated or unresponsive. However, the real world clinic is not necessarily the gildeline world, and I will discuss in this session whether advanced heart failure could be reversed by somewhat belated CRT or not.
SY8-1 Organ Injuries in Acute Heart Failure—Lessons From Registries Naoki Sato; Cardiology and Intensive Care Unit, Nippon Medical School MusashiKosugi Hospital, Japan Lots of registries for acute heart failure (AHF) has been conducted in Asian as well as in western coutries. We could learn lots of stratgies from these registries,which is clarfing theta delayed managements were related to poor outcome. Recently the heart
Heart Failure and Sleep-Disordered Breathing: Impact of Positive Airway Pressure on Patients With Heart Failure Akiomi Yoshihisa, Tetsuro Yokokawa, Satoshi Suzuki, Yasuchika Takeishi; Department of Cardiovascular Medicine, Fukushima Medical University, Japan Heart failure (HF) is mutually associated with sleep-disordered breathing (SDB) including obstructive sleep apnea (OSA) and central sleep apnea (CSA). It has been reported that positive airway pressure (PAP) such as continuous positive airway pressure (CPAP) and adaptive servo ventilation (ASV) improve not only SDB but also pulmonary congestion, cardiac function and partly prognosis. PAP therapy is usually applied for treatment of decompensated HF, and OSA treatment using CPAP is generally accepted in patients with HF and OSA. On the other hand, CSA treatment using CPAP or ASV in patients with HF and CSA is controversial. Recently, SERVE-HF study presented that ASV therapy for HF with left ventricular ejection fraction less than 45% and CSA possibility increased cardiac death. It appears that there are several considerable problems with regard to degree of congestion and cardiac function of HF patients and setting of pressure of ASV. We would like to present the linkage of HF and SDB, impact of PAP on HF patients, and matters that require attention of PAP treatment in HF patients.